经颈内静脉肝内门体分流术联合胃冠状静脉栓塞术治疗门静脉高压症伴上消化道出血的回顾性研究

目的比较单纯性经颈内静脉肝内门体分流术(TIPS)和TIPS联合胃冠状静脉栓塞术(GCVE)急诊治疗门静脉高压症(PHT)伴上消化道出血的安全性及临床疗效。方法 PHT伴上消化道大出血病人76例,其中单纯性TIPS组35例,行单纯性TIPS治疗,TIPS联合GCVE组41例,行TIPS联合GCVE治疗,比较两组病人手术前后门静脉直径、门静脉压力、食管胃底静脉曲张程度、急诊止血率、再出血率、并发症发生率。结果与单纯性TIPS治疗相比,TIPS联合GCVE治疗明显提高病人急诊止血率(82.9%和100%,P0.05),改善食管胃底静脉曲张程度(P0.05)及降低再出血率(17.6%和7.5%,P0.05)。两种治疗方式在门静脉血流动力学变化、支架通畅率及肝性脑病等方面则无明显差异(P0.05)。结论 TIPS联合GCVE治疗PHT伴上消化道出血疗效确切,特别是在急诊止血率、再发出血率及改善静脉曲张程度方面明显优于单纯性TIPS治疗。     

腹腔镜技术在门静脉高压症外科手术中的前景

门静脉高压症(portal hypertension,PHT)是肝硬化病人严重的并发症之一,其临床表现多为食管胃底静脉曲张、脾功能亢进、脾肿大、腹水等.近50％的PHT病人合并食管胃底静脉曲张[1],约30％PHT病人合并食管胃底静脉曲张破裂出血[2-3].食管胃底静脉曲张破裂导致的上消化道出血是 PHT病人死亡的主要...     

经颈静脉肝内门体静脉分流术治疗肝硬化门静脉高压症的研究进展

门静脉高压症（ portal hypertension ,PHT）是由于各种原因导致的门静脉及其主要分支压力增高,引起一系列临床症候群,肝硬化是引起PHT最常见的病因。门静脉压力升高可导致食管胃底静脉曲张破裂出血、顽固性肝性腹水、门静脉高压性胃肠病、淤血性脾肿大、肝性脑病、肝肾综合征、肝肺综合征等多种并发症,其中以食管胃底曲张静脉破裂出血最为严重,是导致患者死亡的主要原因。因此, PHT的治疗原则主要是降低门静脉压力和防治并发症。经颈静脉肝内门体静脉分流术（ transjugular intrahepatic portosystemic shunt ,TIPS）利用外科分流术和断流术的基本原理,经颈静脉入路,在肝静脉与门静脉之间建立分流通道,同时栓塞食管胃底曲张静脉,从而预防和治疗上消化道出血。 TIPS具有低侵袭性、无须全麻、操作难度相对低、安全性高、起效迅速、疗效明显等优势,但肝性脑病和术后分流道狭窄仍是亟待解决的难题。本文就TIPS治疗肝硬化PHT的研究进展做一综述,旨在进一步推广该技术的临床应用。     

断流术联合胃底切除治疗门静脉高压症

目的 探讨断流术加食管下端及胃底切除术治疗门静脉高压的疗效.方法 回顾性分析32例采用断流术联合食管下端及胃底切除术治疗门静脉高压症患者(联合组)的临床资料,并以34例贲门周围血管离断术为对照组,患者均为肝炎后肝硬化,均患有明显的食管胃底静脉曲张,且有1次以上出血史.结果 患者均获随访,平均14个月,两组患者术后门静脉压变化及手术近期病死率比较,差异无统计学意义(P>0.05);食管胃底静脉曲张、术后再出血、腹胀和早期胃潴留等联合组明显优于断流组(P<0.05).结论 断流术联合胃底切除治疗门静脉高压症上消化道出血止血确切,复发出血率低,并发症少,是治疗门静脉高压症较理想的一种手术方法.     

门静脉高压症食管胃底静脉曲张出血的个体化治疗和手术方式选择

肝硬化导致的门静脉高压症(portal hyperten-sion, PHT)在我国十分常见,其引起的食管胃底静脉曲张出血死亡率高,严重威胁病人的生命.近年来,随着药物、内镜技术、介入技术、传统手术和肝移植等治疗方法的兴起和发展,PHT大多行多学科综合治疗.由于PHT病人病情差异很大,病因不同,食管胃底静脉曲张的部位、...     

肝硬化门静脉高压合并门静脉血栓行TIPS治疗临床分析

探讨肝硬化门脉高压合并门静脉血栓行TIPS治疗临床效果。选取2020年1月—2021年12月治疗的肝硬化门脉高压合并门静脉血栓患者92例,分为观察组（n=44）和对照组（n=48）,观察组接受TIPS治疗,对照组给予门静脉置管溶栓治疗,观察两组手术时间、手术费用及手术前后肝功能、凝血功能指标,同时分析食管胃底静脉曲张改善、再出血发生、肝性脑病发生、病死率差异。观察组术后门静脉压力梯度明显低于对照组（P<0.05）。观察组术后食管胃底静脉曲张改善优于对照组（P<0.05）,术后食管胃底静脉曲张治疗有效率为84.09%。观察组和对照组再出血发生率、肝性脑病发生率和病死率比较差异无统计学意义（P>0.05）。在肝硬化门脉高压合并门静脉血栓治疗中,TIPS治疗能明显改善门静脉压力水平及食管胃底静脉曲张程度。     

门静脉高压的介入治疗

<正>门静脉高压症(portal hypertension,PHT)是由于各种原因导致的门静脉及其主要分支压力增高,引起一系列临床症候群,肝硬化是引起PHT最常见的病因。门静脉压力升高可导致食管胃底静脉曲张破裂出血、顽固性肝性腹水、门静脉高压性胃肠病等多种并发症,其中以食管胃底曲张静脉破裂出血最为严重,是导致患者死亡的主要原因。因此,其治疗原则主要是降低门静脉压力和防治并发症。治疗门     

门脉高压静脉曲张的药物治疗现状和前景

几乎所有肝硬化最终都会导致门静脉高压症(portal hypertension,PHT),继而引发各种致命并发症,食管胃底静脉曲张破裂出血(下文简称:静脉曲张出血)是其中最常见的一种.     

分流与断流联合手术在门静脉高压症治疗中的作用

长期以来 ,肝硬化门静脉高压症 (PHT)外科治疗的方法分为分流术和断流术两大类。分流术是最早用于治疗 PHT食管胃底静脉曲张破裂出血的手术方法 ,它具有降压效果满意 ,食管静脉曲张的消失率、止血率以及腹水消失率高等优点。但它可发生二个严重并发症 :1分流性脑病 ,严重影响病     

食管下段、脾脏中VEGF、bFGF的高表达与门静脉高压症食管下段静脉曲张破裂出血的相关性研究

门静脉高压症(PHT)食管静脉曲张破裂大出血是引起PHT患者死亡的常见原因.动物实验证实血管内皮生长因子(VEGF)、碱性成纤维细胞生长因子(bFGF)在PHT高动力循环的形成和食管下段静脉曲张破裂出血中起重要作用.但以往实验多以VEGF检测为主,二者在人类PHT食管下段的联合检测鲜有报道.因此,我们采用免疫组织化学SP法研究30例PHT患者的食管下段和脾脏中VEGF、bFGF的表达以及微血管密度(MVD)的变化情况,现报告如下.     

完全腹腔镜下巨脾切除联合断流术治疗门静脉高压症的体会

目的 探讨完全腹腔镜下巨脾切除联合贲门周围血管离断术治疗肝硬变门静脉高压症的手术技巧和临床应用价值.方法 对我科2009年3月至2010年8月期间,12例肝硬变门静脉高压症致食管下段胃底静脉曲张患者应用超声刀和血管闭合切割系统(Ligasure),行完全腹腔镜下巨脾切除联合贲门周围血管离断术治疗的临床资料进行回顾性分析与总结.结果 12例均在处理脾蒂前夹闭脾动脉,其中10例完成腹腔镜手术(其中7例应用二级脾蒂离断法处理脾蒂),2例中转开腹.10例腹腔镜手术患者的手术时间为180～300 min,平均210min;术中失血200～1000ml,平均480ml;术后住院时间8～15 d,平均9d;术后发生少量(＜300 ml)胸腔积液2例,少量(＜300 ml)腹水2例,轻度(＜10 ml/d)胰瘘1例,均未作特殊处理,带管出院后1个月好转拔管,无死亡病例.12例患者术后平均随访7个月(4～20个月),均未发生再出血.结论 用超声刀预夹闭脾动脉,联合应用超声刀和Ligasure进行二级脾蒂离断法处理脾蒂是完全腹腔镜下巨脾切除联合贲门周围血管离断术成功的关键技术要领,该技术安全、有效、微创,具有一定的临床应用价值.     

Correlation between gastric microcirculation and mucosal injury after surgical therapy of esophageal varices

The correlation between gastric microcirculation and mucosal injury was studied in patients who underwent surgery for esophageal varices. Both mucosal and submucosal blood flow at the lower esophagus, gastric body and antrum was measured using hydrogen gas clearance method through endoscopy in 55 patients including 33 cirrhotics, 10 idiopathic portal hypertensive patients and 12 controls. In 20 cases with esophageal varices, 10 patients were treated with transabdominal esophageal transection (transection group) and 10 with left gastric vena caval shunt (shunt group). The patients with portal hypertension, showed a reduced blood flow in gastric mucosa but increased flow in the submucosa, as compared with the controls. When comparing the postoperative changes in gastric mucosal flow between the two groups, the transection group showed a reduction of mucosal flow by approximately 30% during surgery, and 20% for 4 weeks after operation. In shunt group, the mucosal flow was well preserved with reduction rate less than 10%. Postoperative mucosal injury was endoscopically and histologically found in almost all patients who showed a reduction rate of more than 20%. This study suggests that active protection against possible gastric mucosal lesion should be kept in mind in the setting of surgical therapy for esophageal varices.     

透光技术在胃底静脉结扎术中的应用(附28例报告)

目的探讨透光法胃底静脉结扎＋贲门周围血管离断术治疗门静脉高压症食管胃底静脉曲张破裂出血的可行性。方法收集我院2001年7月～2（1（15年7月门静脉高压症食管胃底静脉曲张破裂出血52例,分为2组：传统断流术组（24例,对照组）和透光断流术组（28例,实验组）。观察所有病人住院期间术后并发症发生率、平均住院天数、平均费用以及食管再出血的例数。术后所有病人随访3年。结果两组之间平均住院天数和平均费用无显著性差异。在随访期内对照组再出血发生率高于实验组（P〈0．01）,实验组再出血时间间隔长于对照组（P〈0．01）。结论透光法胃底静脉结扎＋贲门周围血管离断术治疗门静脉高压症食管胃底静脉曲张破裂出血是一种可行的手术方式,可以减少术后并发症的发生。降低再次出血的风险。     

Esophageal varices evaluated by endoscopic ultrasonography: observation of collateral circulation during non-shunting operations

Summary To clarify the inflow and outflow vessels of esophagogastric varices, we investigated the collateral circulation using endoscopic ultrasonography (EUS; Olympus GF-UM2, 7.5 MHz, radial type) during non-shunting operations in 16 cases of portal hypertension. The main inflow vessels were the left gastric veins and the short gastric veins. The paraesophageal vessels coalescent with esophageal varices were distributed up to 7 cm from the esophagogastric junction. It was possible to devascularize these inflow vessels from the transabdominal approach, and it was also easy to evaluate the complete devascularization by the intraoperative EUS. The main outflow vein seemed to be the azygos arch from the investigation of cross-sectional areas of the azygos system. EUS is very useful in evaluating portal hypertension and in determining the indications and the efficacy of the treatment.     

血管离断术联合经颈静脉肝内门体分流术对门静脉血流动力及肝肾功能的影响

目的分析腹腔镜贲门-胃底周围血管离断联合经颈静脉肝内门体分流术（TIPS）对肝硬化门静脉高压症效果的影响。 方法选择2016年2月至2018年2月宜宾市第二人民医院接受治疗的肝硬化门静脉高压症导致胃底食管静脉曲张患者94例,随机数字表法分成两组,各47例,其中对照组行腹腔镜贲门-胃底周围血管离断术,观察组在对照组基础上行TIPS术,观察两组患者临床疗效、实验室指标以及围手术期门静脉血流动力学。 结果（1）观察组患者总有效率为95.74%（45/47）,显著高于对照组的82.98%（39/47）,差异有统计学意义（Z=5.173,P=0.005）。（2）术后6个月时,观察组患者脾静脉血流量（SVF）、门体压力梯度、门静脉直径（PVD）、脾静脉内径（SVD）、门静脉血流量（PVF）较术前下降,且显著低于同期对照组水平,而脾静脉流速（SVV）及门静脉流速（PVV）较术前升高,显著高于同期对照组水平（P<0.05）。（3）术后1、6个月时,观察组患者血清尿素水平较术前下降,并显著低于同期对照组水平,而白蛋白（ALB）水平较术前上升,显著高于同期对照组水平,术后1个月观察组患者血清丙氨酸氨基转移酶（ALT）、天冬氨酸氨基转移酶（AST）水平高于术前,但低于对照组,术后6个月观察组ALT及AST水平低于术后1个月和对照组（P<0.05）。（4）术后1、6个月时,观察组患者血清内皮素（ET）、血管紧张素Ⅱ（ATⅡ）及血浆肾素活度（PRA）表达水平较术前下降,且显著低于同期对照组水平,差异有统计学意义（P<0.05）。 结论腹腔镜贲门-胃底周围血管离断联合TIPS治疗肝硬化门静脉高压导致的胃底食管静脉曲张,可显著改善患者的肝、肾功能及门静脉血流动力学。     

Clinical significance of the cine-portogram in patients with portal hypertension

A cine-portogram is a new diagnostic modality in portal system. The main purpose of this study is to assess the clinical significance of cine-portogram in patients with portal hypertension. Portal hemodynamics have been evaluated by cine-portogram in 28 patients with portal hypertension. Portal hemodynamics have been analysed in the following five main diagnostic findings: portal hepatic perfusion, hemodynamics of coronary vein, dominance of gastric vein or short gastric vein, extension of varices in lower esophago-proximal gastric region, and route of draining vein of esophageal varices. The grade of portal hepatic perfusion has been evaluated in all cases by cine-portogram. Hemodynamics of coronary vein have been evaluated in 78% of patients. Dominance of the left gastric vein or short gastric vein has been evaluated in 84% of patients. Extension of varices in lower esophago-proximal gastric lesion and route of draining vein of esophageal varices have been evaluated by only cine-portogram. In conclusion, the cine-portogram is a new and useful diagnostic modality for the evaluation of portal hemodynamics in patients with portal hypertension.     

血管生成在肝门部胆管癌发生发展中作用的研究

目的　探讨血管内皮细胞生长因子 (vascularendothelialgrowthfactor,VEGF)和血管生成与肝门部胆管癌发生发展的关系。方法　应用逆转录多聚酶链反应 (RT PCR)和免疫组化技术对2 6例肝门部胆管癌、癌周组织及 12例正常组织中VEGFmRNA和蛋白及微血管密度 (MVD)进行检测。结果　 2 6例肝门部胆管癌组织中VEGFmRNA阳性表达率为 77% (2 0 / 2 6 ) ;癌周组织阳性表达率为2 7% (7/ 2 6 ) ;正常组织表达率为 8% (1/ 12 ) ,三者差异有显著性 (P <0 0 1)。VEGFmRNA阳性表达与VEGF蛋白表达具有一致性 ;VEGFmRNA阳性者MVD值显著高于阴性者 (P <0 0 1) ;VEGFmRNA表达和MVD与肝门部胆管癌的分化程度、浸润转移密切相关 (P <0 0 5 ) ,而与肿瘤发生部位、病理类型、大小、临床分型无关 (P >0 0 5 )。结论　VEGF在肝门部胆管癌的发生和浸润转移过程中发挥重要作用 ,肿瘤血管生成与肝门部胆管癌浸润转移密切相关。     

Prophylactic sclerotherapy in children with esophageal varices: long-term results of a controlled prospective randomized trial

BACKGROUND/PURPOSE: Experience using endoscopic prophylactic sclerotherapy (PS) is restricted to adult patients and has led to conflicting results. There has not been a randomized, controlled study on the use of PS in children. The purpose of this study is to evaluate prospectively the value of PS to prevent the first hemorrhage from esophageal varices in children with portal hypertension and to assess the effect of PS on survival rate. METHODS: In a controlled, prospective, computer-based randomized trial, the effectiveness of PS was analyzed in 100 consecutive children allocated to a group receiving sclerotherapy (n = 50) or to a control group (n = 50) subjected only to regular clinical and endoscopic examinations. Clinical characteristics in both groups were similar. The minimum follow-up period was at least 18 months after the cessation of the sessions of sclerotherapy. RESULTS: After a median follow-up of 4.5 years, PS eliminated the esophageal varices in 47 of 50 (94%) patients but only 38 (76%) of them do not present upper digestive hemorrhage. Before complete obliteration of the varices, upper gastrointestinal bleeding occurred in 12 patients (24%). Six children (12%) had gastric varices, 3 of 6 of whom (50%) bled. Congestive hypertensive gastropathy was observed to occur in 8 (16%) patients, 4 of 8 of which (50%) had hemorrhagic episodes. Two patients bled from undetermined cause. In the control group, only 29 (58%) children remained free from esophageal variceal bleeding and 26 (52%) from any upper gastrointestinal bleeding (P<.05). During the follow-up period, the development of gastric varices was observed in 5 (10%) patients (P>.05) and of congestive hypertensive gastropathy in only 3 (6%) patients (P<.05), but none of them bled. PS does not improve survival rate. CONCLUSIONS: In children with cirrhotic and noncirrhotic portal hypertension, PS reduces the overall incidence of bleeding from esophageal varices that were eradicated in 94% of cases. The source of bleeding has been different in each group, being predominantly from esophageal varices in the control group and from the stomach in the prophylaxis group. When applied with appropriate technique, PS is a safe procedure with a low incidence of minor complications. PS does not change the incidence of gastric varices but increases the development of congestive hypertensive gastropathy. PS increases the risk of bleeding from the naturally formed gastric varices and from congestive hypertensive gastropathy. PS does not affect survival rate.     

联合断流术治疗食管胃底静脉曲张破裂出血

目的：探讨吻合器食管横断联合门奇断流术治疗食管胃底静脉曲张破裂出血的效果。方法：将有食管胃底静脉破裂大出血史的门静脉高压症患者120例，随机分为2组，每组60例。联合断流组实施贲门周围血管离断术加吻合器食管下段横断吻合术，对照组仅实施贲门周围血管离断术。观察对比手术后的近期并发症，以及长期随访结果。结果：（1）联合断流组术后总并发症发生率31.7%，对照组为30.0%（P＞0.05）;（2）术后食管胃底静脉曲张消失率联合断流组优于对照组(P﹤0.01);（3）术后再出血率联合断流组低于对照组(P﹤0.05);(4)两组患者术后肝功能均有不同程度的改善,两组间无统计学差异（P＞0.05）;(5)联合断流组长期（4～7年）生存率（98.3%）高于对照组（90.0% ）(P﹤0.05)。结论：贲门周围血管离断加吻合器食管横断吻合术能更有效地治疗食管胃底静脉曲张，降低再出血率，进一步提高了断流术的疗效。     

经食管内窥镜曲张静脉结扎联合部分脾栓塞术治疗门静脉高压症

目的 研究内镜下食管曲张静脉结扎联合部分脾栓塞术治疗门静脉高压症的临床疗效。方法自1999年5月至2003年2月对68例合并食管静脉曲张和脾功能亢进的门静脉高压症患者实施内镜结扎加部分脾栓塞术进行治疗,观察术后食管曲张静脉闭塞和止血效果及并发症和死亡率,门奇静脉侧支循环情况,并与对照组进行对比。结果联合术后患者食管曲张静脉获得根治,脾功能亢进缓解,门静脉血流速度减慢,血流量减少(P＜0．05),奇静脉血流量降低(P＜0．01),胃左静脉血流速度减慢(P＜0．05)。术后随访2-24个月,未出现复发性出血。结论内镜结扎联合部分脾栓塞术能有效地治疗门静脉高压症食管静脉曲张出血和脾功能亢进,减少了闭塞曲张静脉所需重复结扎次数及近期再出血,对于肝功能较差、难以耐受分流及断流手术的患者尤为适用。